Quality control for cardiac surgery in the Veterans Administration.

The volume of cardiac surgical procedures and the 30-day mortality associated with them were reviewed for the total experience of 72 Veterans Administration medical centers over a 10-year period (1975 to 1984). The total number of cardiopulmonary bypass operations increased from 3,074 in 1975 to 6,455 in 1984, whereas operative mortality declined from 8.3 to 4.7%. Operative mortality associated with isolated valve replacement operations declined from 10.9 to 5.9%. Aortocoronary vein bypass operations, which increased in number from 1,679 to 4,988 over the 10-year period, were associated with an operative mortality of 4.7% in 1975 and 3.6% in 1984. The extent of the patient's disease accounted for most of the operative mortality, but problems related to the adequacy of myocardial protection and the surgical technique were also important factors. These data were compared with similar comprehensive statistics compiled by the New York State Department of Health over a five-year period (1979-1983). Operative mortality rates were quite similar for aortocoronary bypass procedures, mitral valve replacements, and total cardiac operations. However, operative mortality for aortic valve procedures was higher among the Veterans Administration hospitals. In the future, if operative risk factors are clearly defined, a more meaningful comparison of operative mortality among ongoing reviews, such as those being carried out by the Veterans Administration and by New York State, could be used to establish standards of performance for cardiac surgery.

A 20-year review of ostium primum defect repair in children.

Between July, 1963, and July, 1983, a total of 69 patients (35 boys and 34 girls) underwent ostium primum defect repair. There were four perioperative deaths and four patients were subsequently lost to follow-up, leaving 61 children followed for 6 months to 20 years (mean 5 years). Results of surgery were assessed by cardiac catheterization in 17 of 61 patients, while the remaining patients were evaluated noninvasively. Postoperative mitral insufficiency was found to be absent in 19 patients, mild to trivial in 35, moderate in four, and severe in two. Four patients were found to have large residual atrial septal defects. Significant late postoperative arrhythmias were found in 14 of 61 patients. The types of arrhythmias included isolated complete atrioventricular block in 5 of 14, complete atrioventricular block with sinus node dysfunction in 2 of 14, and isolated sinus node dysfunction in 7 of 14. Pacemakers have been implanted in 8 of 14 of these patients. Based on this 20-year review of a large number of children: (1) ostium primum defect repair is associated with a low mortality rate, (2) residual mitral insufficiency although common is usually mild to trivial and nonprogressive, and (3) significant arrhythmias are a frequent complication and often require pacemaker implantation.

Activated coagulation and activated partial thromboplastin times in assessment and reversal of heparin-induced anticoagulation for cardiopulmonary bypass.

In 22 adult patients, activated coagulation times (ACT) were compared to activated partial thromboplastin times (aPTT) before, during, and after cardiopulmonary (CP) bypass surgery. After intravenous heparin (150 units/kg), mean ACT increased from 131 +/- 14 (mean +/- SD) to 362 +/- 72 s (P less than 0.001). With 1.5 units of heparin/ml added to the priming solution of the pump, ACT ranged from 230 to 541 s and aPTT was always 300 s or longer. Activated PTT appears to be less sensitive to changing plasma heparin levels than ACT. Heparin neutralization with a protamine/heparin ratio of 1.0 returned ACT and aPTT to preheparin levels. No abnormal bleeding tendency was seen during the recovery period, and ACT and aPTT remained at preheparin levels. In 10 infants and children undergoing open-heart surgery, ACT was measured in response to the same heparin and protamine regimen. Baseline (113 +/- 14 s) and post-heparin (297 +/- 90 s) ACT were shorter in children than in adults (P less than 0.01). After protamine, ACT was still longer than baseline (134 v 113 s, P less than 0.05). Infants and children seem to require more heparin/kg body weight than adults to achieve comparable ACT levels.

Surgical therapy for congenital aortic valvular stenosis. A 23 year experience.

This is a review of 70 consecutive patients (2 to 20 years old) who underwent valvotomy for congenital aortic valvular stenosis from 1958 through 1980. A tricuspid valve was created in 36, a bicuspid valve in 33, and a valve prosthesis was inserted in one, with two operative deaths (2.8%). There were four late deaths, three due to noncardiac causes. Eleven patients required reoperation from 2 to 21 years (mean 11.3 years) after valvotomy, with two deaths. Seven patients underwent valve replacement. One patient died 9 years after a second valvotomy. The overall survival rate including reoperation was 92.6% for 10 years and 86% for 15 years. Of 53 surviving patients free of reoperation, 49 are in New York Heart Association Class I and four are in Class II. One of the patients in Class II is a candidate for reoperation. The other 52 patients are well. Twenty-three have normal stress tests, and only one of 24 studied has a pressure gradient greater than 50 mm Hg. We concluded from this experience that valvotomy effectively and safely relieves left ventricular outflow tract (LVOT) obstruction produced by congenital aortic valvular stenosis. It delays the time when a prosthetic device will be required to relieve LVOT obstruction.

Assurance.

The Society of Thoracic Surgeons was created for practicing thoracic surgeons, but the response to recertification indicates there has been a breakdown in communication between practicing thoracic surgeons and the leadership of this Society and other decision-making organizations of our specialty. To provide greater input and participation by members, it is suggested that regional representatives be elected to the Council, open discussion of issues important to thoracic surgeons be held at the Annual Meetings, small-group clinical workshops be added to the Scientific Sessions to increase opportunity for participation, and more nonacademic surgeons be included as members of working committees of the Society. Recertification represents the third phase on the part of the medical education and establishment of standards for postgraduate training. The members' response to a questionnaire concerning recertification indicates they agree that periodic review of competence should be available and that they are willing to undergo peer review and fulfill requirements for continuing medical education participation. They are opposed to multiple-choice, cognitive examinations but would be in favor of a self-education/self-assessment program to review knowledge. The periodic review of competence should require review of performance, and a mechanism for accomplishing this must be developed.

Severe aortic stenosis in a patient with recurrent gastrointestinal bleeding: replacement of the aortic valve with a porcine xenograft.

Patients with aortic stenosis are subject to recurrent episodes of gastrointestinal bleeding of uncertain cause. How such patients should be handled when aortic valve replacement is required is not established. This report deals with such a patient who underwent successful aortic valve replacement with a porcine xenograft without anticoagulation. The patient has had no recurrent gastrointestinal bleeding since the valve replacement. The use of the now widely available porcine xenograft for aortic valve replacement avoids the need for anticoagulants in patients with a history of recurrent gastrointestinal bleeding. This case and limited data from the medical literature suggest that recurrent gastrointestinal bleeding after aortic valve replacement may be uncommon.

Coronary artery bypass grafts: increased flow in the early postoperative period.

The long-term outcome of coronary artery bypass operations is contingent upon the patency of aortocoronary bypass grafts. Flow measurements taken at operation may not truly reflect the capacity of the graft to carry glow because the heart may not have fully recovered from the consequences of ischemic arrest, despite the protective effects of hypothermic cardioplegia. During a three-year period, we observed increases of up to 200% in the flow rate of 8 of 11 saphenous vein grafts in 7 patients who underwent reoperation for bleeding or cardiac tamponade in the early postoperative period. At initial operation, flow rates ranged from 25 ml/min to 130 ml/min (mean value, 66.8 +/- 10.3 ml/min [standard error of the mean]). At reexploration, flow measurements ranged from 0 ml/min (graft clotted) to 260 ml/min (mean value, 110 +/- 22.8 ml/min). This difference was statistically significant (p less than 0.02). This study documents that flow rate measurements in saphenous vein aorotocoronary bypass grafts can increase in the early postoperative period although the exact mechanism by which this occurs is not known.

Surgical repair of inferior sinus venosus atrial septal defect.

A 9-year-old girl presented for cardiac evaluation with symptoms of dyspena, fatigue, and cyanosis with exercise. Cardiac catheterization demonstrated an atrial septal defect; an anomalous right superior pulmonary vein was suspected but not confirmed. Operation disclosed anomalous drainage of the right superior and inferior pulmonary veins into the right atrium, an intact fossa ovalis, and an inferior sinus venosus defect. Repair was accomplished by detaching the posterior edge of the atrial septum and suturing it to the right of the pulmonary veins, so that the defect was closed and all the pulmonary venous blood was directed to the left atrium.

Comparison of exercise and catheterization results following total surgical correction of tetralogy of Fallot.

Although surgery may correct the hemodynamic abnormalities of tetralogy of Fallot (TOF), the long-term effects on exercise tolerance are uncertain. Twenty-eight patients, aged 7 to 30 years, had cardiac catheterization and maximal graded exercise testing to evaluate the adequacy of the ehmodynamic repair and its relation to exercise performance. Patients were tested 2 to 9 years after operation, and 13 previously had had palliative shunt procedures. At catheterization, 23 of the 28 patients had good surgical results. Despite the satisfactory hemodynamics, maximal working capcity (MWC), maximum heart rate, and exercise blood pressure were diminished when compared to normal values. In 10 patients who had exercise studies at catheterization, right ventricular systolic pressure (RVSP) and residual gradients were magnified by exercise. Abnormalities were independent of age at time of correction, time elapsed since surgery, use of patch in the outflow tract, or any antecedent procedures.

Resolution of surgically induced right bundle-branch block.

In a retrospective study, the serial electrocardiograms of all patients with surgically induced right bundle-branch block (RBBB) were reviewed. None of these patients had had RBBB prior to operation. Seven patients who had RBBB from 6 to 16 days after operation showed resolution in ECGs done 3 to 8 months later. Two patients are reported, with documentation by vectorcardiogram, in whom RBBB resolved by 3 and 12 years after operation. The origin of transient forms of RBBB may be different from the long-standing form. If RBBB of long duration is due to operative injury to the proximal right bundle, Purkinje fiber network, or distal branch or branches of the right bundle, or to combinations of these tracts, one may speculate about the possibility of regeneration of the right ventricular conduction system. Since no data are available concerning the long-term prognosis of RBBB and since a progressive conduction disturbance can occur, the resolution of RBBB after many years might carry a better prognosis than its persistence.

Congenitally cleft atrioventricular valves associated with secundum atrial septal defects.

Three patients with the rare association of secundum ASD and congenital clefts of A-V valves are reported. These three patients illustrate the predictive valve of vectoracardiographic analysis in precisely determining the anatomic location of the valvular pathology. The embryologic origins of the lesion are briefly discussed. A review of the literature supports the use of vector analysis in the evaluation of the patients with this type of heart disease.